PAR-Q & YOU
(A questionnaire for People Aged 15-69)
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most
people. However, some people should check with your doctor before you start.
If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages
of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active,
check with your doctor.
Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO
YES
NO
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended
by a doctor?
YES
NO
2. Do you feel pain in your chest when you do physical activity?
YES
NO
3. In the past month, have you had chest pain when you were not doing physical activity?
YES
NO
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
YES
NO
5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your
physical activity?
YES
NO
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
YES
NO
7. Do you have a diabetes or thyroid condition?
YES
NO
8. Do you know of any other reason why you should not do physical activity?
YES to one or more questions
If you
A medical clearance form is required of all participants who answer ‘yes’ to any of the eight PAR-Q questions.
answered Note: Personal training staff reserve the right to require medical clearance from any client they feel may be at risk.
•
“Yes”:
•
Discuss with your personal doctor any conditions that may affect your exercise program.
All precautions must be documented on the medical clearance form by your personal doctor.
NO to all questions
If you answered NO honestly to all PAR-Q questions, you can be reasonably
sure that you can:
•
start becoming much more physically active - begin slowly and
build up gradually. This is the safest and easiest way to go.
take part in a fitness appraisal - this is an excellent way to
•
determine your basic fitness so that you can plan the best way
for you to live actively. It is also highly recommended that you
have your blood pressure evaluated. If your reading is over
144/94, talk with your doctor before you start becoming much
more physically active.
DELAY BECOMING MUCH MORE ACTIVE:
•
If you are not feeling well because of a temporary illness
such a cold or a fever - wait until you feel better; or
•
If you are or may be pregnant - talk to your doctor before
you start becoming more active.
PLEASE NOTE: If your health changes so that you then answer YES
to any of the above questions, tell your fitness or health professionals.
Ask whether you should change your physical activity plan.
Informed Use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability to persons who undertake physical activity, and if in doubt after completing this
questionnaire, consult your doctor prior to physical activity.
NOTE: If the PAR-Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section may be used for legal or administrative purposes.
“I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.”
NAME
SIGNATURE
DATE
SIGNATURE OF PARENT
or GUARDIAN (for participants under the age of majority)
WITNESS
Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and
becomes invalid if your condition changes so that you would answer YES to any of the seven questions.
Supported by:
Physical Activity Readiness Questionnaire – PAR-Q
(revised 2006 by CW)
UNIVERSITY OF WASHINGTON
DEPARTMENT OF RECREATIONAL SPORTS P ROGRAMS
PERSONAL TRAINING REGISTRATION – FIRST-TIME CLIENT
Priority given to current UW students and faculty & staff IMA members. Spouses and registered same sex domestic
partners eligible on a space available basis.
Please write legibly.
Name
Email
Phone (h)_
(w)
Please indicate the days and times you would most be available for your first appointment. Please allow
approximately one week’s notice for appointments.
DAY OF WEEK
DATES AVAILABLE
TIMES AVAILABLE
(if applicable)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Personal Trainer preference:
Welcome to Personal Training with the UW Department of Recreational Sports Programs. We have a
knowledgeable, talented staff that will assess your fitness level and design an exercise program that will meet
your personal needs and interests. To get the most from your session(s), please observe the Client Information
Sheet included in this packet.
By signing below, you have read and agree to the terms and policies of the IMA Personal Training Program. These policies
are located on the last page of this packet and may be taken home with you. In addition, I attest that I have answered the
PAR-Q truthfully and to the best of my knowledge. I agree to supply the Medical Clearance Form to the Personal Training
Program staff if I answered ‘Yes’ to any of the seven PAR-Q questions. I understand that all forms must be submitted and
payment made before scheduling can occur, this includes the Medical Clearance Form, if applicable.
If you have diabetes or a thyroid problem, a Medical Clearance IS required and must be submitted prior to scheduling.
Signature
Date
OFFICE USE ONLY
Membership Type (circle):
Student
Faculty
Staff
Membership Expiration:
Spouse/Partner
Office Staff Initials:
_/
Registration Processing:
_/_
/
/_
CONFIDENTIAL [Information to be used by training staff only & kept in a locked, confidential file]
UNIVERSITY WASHINGTON
DEPARTMENT OF RECREATIONAL SPORTS P ROGRAMS
PERSONAL TRAINING
Name:_
PREPARTICIPATION PHYSICAL EVALUATION
Sex:
Age:
Date of Birth:
/
/
Date of Evaluation:
Explain “Yes” answers below. Circle questions you do not know the answer to.
Yes No
6. Recent surgery (less than 12 months)
1. Do you have an ongoing or chronic illness?
2. Are you currently taking any prescriptions
or nonprescription (over-the-counter) medications
or pills or using an inhaler?
3. Have you had high blood pressure or high
cholesterol?
4. Have you ever had a head injury, concussion,
or seizure?
5. Have you had any problems with pain or swelling
in muscles, tendons, bones, or joints?
If yes, check the appropriate box below.
Head
Elbow
Neck
Forearm
Back
Wrist
Chest
Hand
Shoulder
Finger
Upper arm
7. Diabetes or thyroid condition?
FEMALES ONLY
8. Are you currently pregnant?
9. Have you recently (within one year) given birth?
Explain “Yes” answers here:
Hip
Thigh
Knee
Shin/ca
Ankle
Foot
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of client
Date
OFFICE USE ONLY
General Physiological Information:
Height
ft.
in.
Blood Pressure
Weight
mm Hg RHR
Systolic/Diastolic
Predicted Max HR
80%
70%
60%
Body Composition:
A. Skin Folds
Chest
Suprailiac
Abdominal
Tricep
Ant. Thigh
TRAINER NOTES:
Total Skin Folds
B. Body Fat
Percent Fat
%
/
/
Yes No
CONFIDENTIAL [Information to be used by training staff only & kept in a locked, confidential file]
UNIVERSITY OF WASHINGTON
DEPARTMENT OF RECREATIONAL SPORTS P ROGRAMS
PERSONAL TRAINING
FITNESS INTEGRATION FORM
Name
Email
Please answer all questions to the best of your knowledge. Circle your answer.
1. Which area of behavior would you most like to change to improve your health?
a. Exercise
b. Nutrition
c. Weight Management
d. Smoking
e. Stress Management
2. Has anyone in your immediate family had heart problems, high cholesterol, or
experienced sudden death at 55 years of age?
a. Yes
b. No
3. Do you have diabetes or a thyroid problem?
a. Yes
b. No
4. Have you ever lost 10% of your weight through dieting/exercise then gained it back?
a. Yes
b. No
5. How do you feel about your current weight?
a. Would like to lose
b. Would like to gain
c. Satisfied with weight
6. Do you currently accumulate at least 30 minutes of moderate to high intensity activity on
most days of the week?
a. Yes
b. No
7. On average, how many times a week do you perform aerobic exercise for at least 20
consecutive minutes?
a. Never
b. Less than one time
c. One to two times a week
d. Three or more time for a week
8. When you do aerobic exercise, approximately how long do you spend performing the
activity?
a. Less than 20 minutes
b. 20-30 minutes
c. 30-60 minutes
d. More than 60 minutes
9. Do you participate in resistance training activities?
a. Yes
b. No
10. How often do you stretch your muscles in order to increase your flexibility
a. Never
b. Occasionally
c. Often
11. What is the biggest barrier to increasing/maintaining your level of exercise?
a. Not enough time
b. Cost
c. Lack of appropriate facility or equipment
d. No one to exercise with
e. Physical incapacity
f. None
g. Other
12. Do you think your current level of stress is high enough to affect your health or quality of
life?
a. Yes
b. No
c. Not sure
11. Please rank your reasons for beginning an exercise program ( 1 = highest priority)
Lose body fat
Stress release
Meet similar folk
Family recreation
Strengthen/Tone
Self-esteem increase
12. If you are presently exercising, briefly describe your program:
13. How much time can you comfortably allocate per workout session base on your lifestyle?
Circle the answer that most closely applies:
a. 45 minutes or less
b. 45-60 minutes
c. 60-90 minutes
14. What days of the week do you see yourself using the IMA (circle) S M T W R F S
Time of day?
15. Briefly describe goal(s) you have set to attain from your exercise program:
16. What type of coaching/support would benefit you most (motivation)?
17. Are there any other factors affecting your current level of fitness?
Staff Notes:
UNIVERSITY OF WASHINGTON
DEPARTMENT OF RECREATIONAL SPORTS P ROGRAMS
PERSONAL TRAINING
ASSUMPTION OF LIABILITY AND RISK AGREEMENT
I acknowledge that participating in personal training is a dangerous activity with the potential for death, serious
injury, and property loss. I realize that the inherent risks of participating in a personal training program include
injuries due to equipment failure, bad decision-making, and my underlying physical and mental condition. I
understand that unforeseeable accidents occur and I assume all risks associated with such accidents, even
though I or the UW staff cannot foresee them.
I agree to pay attention to the condition of all equipment and to advise the facility staff if I do any damage or
notice any damage. I agree to abide by all gym rules, and if the facility staff makes a specific request of or
instruction to me, I agree to comply.
I certify that I am physically capable of participating in personal training activities and have informed the staff of
any medical or health conditions I have that may affect theses activities. I agree to supply a doctor’s note
(Medical Clearance Form) should I have experienced any of the following conditions: chest pain while
exercising, chest pain while not exercising, loss of balance because of dizziness, loss of consciousness, bone or
joint problem that could worsen as a result of physical activity, prescribed medication for blood pressure or heart
condition, doctor’s indication of a heart condition, or any other reason why I should not partake in
physical activity. In addition, I agree to inform the staff of any changes in my medical or health condition while a
participant in this program.
I give permission for the facility staff to seek emergency medical services for me should I become injured or ill
with the understanding that I am responsible for any expenses incurred. I fully understand that the University
of Washington does not provide any medical insurance coverage for me while participating in this facility or
offsite.
I agree to assume all risk of personal injury, including paralysis, death, or other permanent disability, medical
expenses, lost wages, loss of earning capacity, and property damages and loss incurred while participating at
the Department of Recreational Sports Programs, Personal Training Services Program.
I HAVE CAREFULLY READ THIS AGREEMENT. I FULLY UNDERSTAND ITS CONTENTS AND
SIGN IT OF MY OWN FREE WILL.
Signature:
Date:
(Parental Consent Form must also be signed by parent or legal guardian if participant is a minor under 18 years of age.)
Printed Name:
Date of Birth:
Local Address:
Phone:
City:
State:
Zip Code:
UW Student ID or UW Faculty/Staff ID #
In case of emergency please contact:
Name:
Relationship:
Address:
Phone:
City:
State:
Zip Code:
CONFIDENTIAL [Information to be used by training staff only & kept in a locked, confidential file]
UNIVERSITY OF WASHINGTON
DEPARTMENT OF R ECREATIONAL S PORTS P ROGRAMS
PERSONAL TRAINING
MEDICAL CLEARANCE FORM
Dear Doctor:
wishes to start a personalized training program at
name of applicant
University of Washington, Department of Recreational Sports Programs. The Personal Training
package includes an exercise screening (body composition analysis, blood pressure and resting
heart rate checks, and height and weight measurements), consultation, and on-the-floor training.
The exercise program is designed to start easy and become progressively more difficult over a
period of time. Both resistance and cardiovascular training exercises may be part of the client’s
program. All exercise screenings and exercise programs will be administered by personal trainers
trained in conducting exercise screenings and developing exercise programs.
By completing the form below, however, you are not assuming any responsibility for our
administration of the exercise screening and/or exercise programs. If you know of any medical or
other reasons why participation in the exercise screening and/or exercise programs by the
applicant would be unwise, please indicate so on this form.
If you have any questions about the University of Washington exercise screening procedures
and/or exercise programs, please call the Fitness Coordinator at 206-616-2072. Please call our
offices at 206-543-2571 if you plan on faxing the completed form to us (Fax: 206-685-4661).
Report of Physician
I know of no reason why the applicant may not participate.
I believe the applicant can participate, but I urge caution because
The applicant should not engage in following activities:
I recommend the applicant NOT participate.
Physician’s signature
Date
Address
Phone
UNIVERSITY OF WASHINGTON
DEPARTMENT OF RECREATIONAL S PORTS P ROGRAMS
PERSONAL TRAINING
INFORMATION
Registration: All clients must be IMA members in order to use personal
training services.
First-time clients are required to purchase the Fitness Introductory Package
(described on back). Paperwork must be completed and turned in to the
Programs Office in person (3rd floor IMA, Mon – Fri, 8:30 am – 5:00 pm).
You may request a trainer or one will be assigned to you based on your
needs and availability. Trainer schedules are posted on the Personal
Training Program website and at the Programs Office; schedules and
availability are subject to change.
After the paperwork has been processed, the personal trainer will contact
you via email within three (3) business days of your registration to schedule
your first appointment. If you do not receive an email from a trainer, please
contact the Fitness Coordinator at 206-616-2072.
Please allow a minimum of one week advance notice for all first-time
client appointments. At peak times (beginning of the academic quarter;
January) longer wait times may apply.
Returning clients may purchase additional sessions via fax, mail or in person.
Note: Personal trainers DO NOT hold office hours. Personal trainers are
hourly employees of the University.
CLIENT INFORMATION SHEET
POLICIES & PROCEDURE
PAR-Q & Medical Clearance: A medical clearance form is required of all
participants who answer ‘yes’ to any of the PAR-Q questions and/or those
who have a diabetes or thyroid condition. Note: Personal training staff
reserve the right to require medical clearance from any client they feel may
be at risk.
Session Duration: All personal training sessions are one hour. Trainings may
also be 30 minutes in length and will count for half of a session (not
applicable on a Fitness Introductory Package, 1 Session, or partner training).
Attire: Come prepared to each training session in proper workout attire and
footwear (shorts, gym pants, T-shirt, supportive sneakers). Participants
arriving unprepared for their training session will lose the session.
Late Policy: Clients are responsible for arriving on time to their training
sessions. Trainers are only obligated to wait 15 minutes (10 minutes for 30minute sessions). After 15 minutes (10 minutes), the trainer is not required
to lead the remaining time of the session and the client is charged for the
session.
Cancellation Policy: Clients should email their trainer 24 hours in advance to
cancel a scheduled session. Clients are charged for appointments cancelled
with less than 24 hours notice.
Package Expiration/Refund Policy: Clients must complete all personal
training sessions by the end of their eligibility to participate in the program
(current IMA membership) or by the expiration date of the training package,
whichever comes first. All personal training packages expire six (6) months
from the date of purchase. All packages are non-refundable/nontransferable.
NEW CLIENTS
PACKAGES: STUDENT RATE
FITNESS INTRODUCTORY PACKAGE…….………………………………………..$60.00*
All new clients to personal training will meet with a certified personal
trainer in the Personal Training Office (#208) for our Fitness Introductory
Package. This appointment is 1.5 hours.
The first 30-minutes consists of an exercise screening, which includes blood
pressure reading, resting heart rate check and body composition. The client
and trainer will consult about the results of the screening and any other
areas of concern reported in the client’s health history and paperwork.
The last hour will include on-the-floor personal training. The client will be
sent home with the results of their exercise screening and a workout
routine developed by the trainer.
All forms (including the Medical Clearance form, if applicable) MUST be
submitted in-person BEFORE scheduling can occur.
Note: Personal training staff may not conduct partner or 30-minute sessions.
It is advised to check with the trainer before requesting such appointments.
Only one trainer may be used per package purchase. All training sessions
must be purchased BEFORE scheduling with a trainer.
ONE PERSON
1 SESSION ………………….…………….……..…..$38.00*
4 SESSIONS…………………………………….…..$140.00*
8 SESSIONS ………….………………….….……..$265.00*
12 SESSIONS………….…………..…….….……..$360.00*
30-minute appointments can only be applied to 4, 8 or 12 sessions.
PARTNER TRAINING
To get the most out of your partner session it is recommended both clients
have similar fitness goals and abilities.
4 SESSIONS………………………………….…….$210.00*
8 SESSIONS ………………………………….…….$360.00*
12 SESSIONS ……………………………….…….$480.00*
30-minute appointments are not applicable for Partner Training.
PACKAGES: FACULTY/STAFF/SPOUSE/DP RATE
Only one trainer may be used per package purchase. All training sessions
must be purchased BEFORE scheduling with a trainer.
ONE PERSON
1 SESSION ………………….…………….……..…..$48.00*
4 SESSIONS…………..……………….……….…..$180.00*
8 SESSIONS ………….…………….…….….……..$345.00*
12 SESSIONS………….…………..…….….……..$480.00*
30-minute appointments can only be applied to 4, 8 or 12 sessions.
PARTNER TRAINING
To get the most out of your partner session it is recommended both clients
have similar fitness goals and abilities.
4 SESSIONS……………..…………………….…….$250.00*
8 SESSIONS ……………………………….….…….$440.00*
12 SESSIONS ……………………………..….…….$600.00*
30-minute appointments are not applicable for Partner Training.
*Personal training purchases subject to Washington State sales tax.